Extubation with airway exchange catheter

Airway exchange catheters are described here.

This device serves two purposes at the time of extubation and immediately after:

  1. It allows administration of oxygen through its central lumen directly into the trachea if the airway is not sufficiently patent after extubation/ removal of the ET tube.

Note that due to the fairly high internal resistance of airway exchange catheters, no actual ventilation or delivery of significant tidal volumes is possible. These devices are only designed to achieve (some degree of) oxygen insufflation

  1. It can serve as a conduit for an ET tube if urgent re-intubation is required and laryngoscopy is difficult (see below: 'Re-intubation over an in-situ airway exchange catheter').

Other options are to postpone extubation

INDICATIONS

This techique is mentioned as an option in the 'at risk' algorithm of the Difficult Airway Society (DAS) extubation guidelines. An 'at risk' extubation refers to an extubation where airway patency after ET tube removal is somewhat uncertain and/ or where re-intubation might be challenging.

Clinical examples: Swelling, c-spine fusion reducing effectiveness of basic airway maneuvers to create a patent airway, ..


EQUIPMENT

You will need...

  1. an airway exchange catheter,
  2. a swivel adapter,
  3. a device for oxygen insufflation through the airway exchange catheter such as a self-inflating Ambu Bag or a Jackson-Rees breathing circuit

Can be done without the swivel adapter, but adapter allows ongoing oxygen delivery/ effective pre-oxygenation right up until the moment the ET tube is removed


TECHNIQUE

1. Prepare for urgent re-intubation

Since this technique is used in situations where there is a concern that (urgent) re-intubation might become necessary after extubation you should prepare appropriate drugs and equipment ahead of time. In practice, this means (in most circumstances) drawing up an induction dose of propofol, an intubation dose of succinylcholine, and having a laryngoscope ready.

2. Connect swivel adapter
3. Advance airway exchange catheter

Advance the airway exchange catheter through the swivel adapter into the ET tube. Avoid excessive advancement of the airway exchange catheter to reduce the risk of iatrogenic trauma to the lower airways. Pay attention to the insertion depth!

The airway exchange catheters have length markings on them that are visible through the wall of standard ET tubes. Insert the catheter to the same length at the patients teeth/ gums as you would for an ET tube, i.e. around 21 to 24 cm depending on patient habitus.

4. Apply the usual extubation criteria

Use the same criteria to assess patient 'readiness' for extubation as you would in any other patient.

CAUTION: The presence of an airway exchange catheter should not tempt you into early or deep extubation; do not remove tube before you would if no echange cathere was in-situ; this is not a technique for deep extubation!

5. Withdraw ETT onto catheter while maintaing depth
6. Apply anesthetic facemask and check for airway patency

and respiratory gas exchange in usual fashion (mask misting, chest wall signs of obstructiuon, bag movement, expired tidal volume measurements, end-tidal CO2)

Do not discard the ET tube

ETT can stay on exchange catheter to facilitate fast re-intubation if needed. It might be advisable to downsize the ET tube if re-intubation is needed.

7. Tape exchange catheter to face

Reduces the risk of it falling out and reduces inadvertent back and forth movement of the catheter triggering violent coughing

8. Remove catheter when ready

Re-intubation over an in-situ airway exchange catheter

The techniques used here is essentially the same as for an ET tube exchange over a gum-elastic bougie. Laryngoscopy is helpful to move tissue out of the way, reduce risk of trauma. Appreciate step up between tube and exchange catheter. Err on the side of using a smaller ET tube.


REFERENCES

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